Hepatocellular carcinoma (HCC) is the third leading cause of death from cancer worldwide. Despite overall advances in the treatment of HCC, racial/ethnic minorities continue to exhibit worse survival than Caucasians. The mechanisms behind this discrepancy remain poorly understood. Liver transplantation is the single best treatment for HCC, however minorities undergo transplantation less often than Caucasians, even with similarly staged tumors. This may be because requirements for organ allocation disproportionately exclude minority groups, and may represent a potential point of discrimination. Specific Aim 1. To assess the relationship between low transplantation rates and HCC survival disparity in racial/ethnic minorities compared to Caucasians Our first aim is to examine what factors, including bias, contribute to the lower rates of transplantation and whether these lower rates are the main determinant of poor prognosis in minorities. We will address this aim using Propensity Score Matching, a statistical method used to compare groups with complex background information. We hypothesize that (1) minority and Caucasian groups will have statistically different Propensity Scores, but that (2) this difference will not be proportionate to the disparity in transplantation rates, suggesting the presence of treatment bias; and that (3) individuals matched by Propensity Scores will have similar survival - thereby establishing lack of transplantation as the major determinant of poor HCC survival in minorities. We will conduct a subgroup analysis specifically examining Asian minorities, since this group has especially high rates of HCC. Specific Aim 2. To explore attitudes on HCC treatment in the New York City Chinese community, and investigate perceived reasons why they undergo liver transplantation less frequently than Caucasians Second, we aim to explore perceived reasons Chinese minority groups undergo liver transplantation less frequently than Caucasians. By communicating directly, we will be able explore qualitative issues such as perception of provider treatment bias, and presence of social support networks. For this aim we will employ focus groups and Social Cognitive Theory to study the attitudes and knowledge about HCC and liver transplantation in a minority HCC community. While much of the existing literature has focused on noting the presence of disparities in cancer outcomes, this application is innovative in its attempt to elucidate the underlying mechanism for these disparities. Interventions to reduce disparities are inherently more successful when the underlying mechanism is well understood. Determining whether transplantation barriers are largely responsible for poor outcomes in minority patients, and how this occurs, will allow us to address this disparity and lead to improvements in survival for patients with HCC. PUBLIC HEALTH RELEVANCE: Project Narrative Racial/ethnic minorities have a worse prognosis from liver cancer, although the exact reasons for this remain poorly understood. Liver transplantation is the best treatment for liver cancer, and our work will examine whether transplantation policies exclude minorities, thus affecting their outcome. Information gained from this project will be used to understand and attempt to resolve disparities in liver cancer survival